Members of a Senate subcommittee are accusing UnitedHealthcare of using artificial intelligence (AI) to unfairly reject Medicare Advantage claims.
A report released in October by the U.S. Senate Permanent Subcommittee on Investigations (PSI) revealed that UnitedHealthcare’s denial of claims for post-acute care increased significantly. The rejection rate rose from 10.9% in 2020 to 22.7% in 2022. Claims for skilled nursing care were hit the hardest, with denials in 2022 being nine times higher than in 2019.
During this period, UnitedHealthcare increased its use of automation, including AI, to speed up claim processing. The report also found that UnitedHealthcare approved more home health service requests, which are cheaper, suggesting the company was pushing patients toward less costly care instead of post-acute care facilities.
UnitedHealthcare responded to the report by stating that it misrepresents the Medicare Advantage program and its clinical practices. The company said it follows the rules set by the Centers for Medicare and Medicaid Services (CMS) for reviewing post-acute care.
The report highlighted a decision made by UnitedHealthcare in April 2021, where the company approved the use of a system called “Machine Assisted Prior Authorization” to speed up how medical requests are reviewed.
This system allowed doctors and nurses to review claims 6-10 minutes faster. However, it also led to more denials as the system flagged errors that might have been missed in the past.
In December 2022, UnitedHealthcare tested how AI and machine learning could predict which denials would likely be appealed and overturned. Nearly a year later, in November 2023, UnitedHealthcare faced a class-action lawsuit.
The lawsuit accused UnitedHealthcare and its subsidiary NaviHealth of using AI to wrongly deny claims for elderly patients in nursing homes. It claimed that the AI system replaced doctors’ decisions about the type of care patients needed.
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The lawsuit also claimed that the AI system has a 90% error rate. However, it alleged that UnitedHealthcare continued to use it because only a small number of patients (about 0.2%) appeal the denials. As a result, most patients either pay for care themselves or give up on receiving the care they need.
How it works:
The nH Predict algorithm, created by NaviHealth, analyzes a patient’s medical information to predict the level of care they will need after leaving the hospital. It takes into account factors like the patient’s age, health condition, and physical abilities to estimate the duration of care required.
- Data Collection: The system gathers the patient’s medical history, including their age, diagnosis, and ability to carry out daily tasks.
- Data Analysis: It reviews the patient’s information and compares it to a large database of similar cases.
- Prediction: Based on the analysis, the system predicts how long the patient will need post-acute care and sets a possible discharge date.
- Decision Making: Insurance providers, like UnitedHealthcare, use these predictions to determine whether to approve or deny continued care for the patient.
